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Assessing Value in Ontario Health Links. Part 3: Measures of System Performance in Ontario’S Health Links

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Assessing Value in Ontario Health Links. Part 3: Measures of System Performance in Ontario’S Health Links Assessing Value in Ontario Health Links. Part 3: Measures of System Performance in Ontario’s Health Links Applied Health Research Question Series Volume 4.3 Health System Performance Research Network Report Prepared by: Dr. Seija Kromm, Luke Mondor, Dr. Walter P Wodchis January 2015 1 Acknowledgements The Health System Performance Research Network (HSPRN) is a multi-university and multi-institutional network of researchers who work closely with policy and provider decision makers to find ways to better manage the health system. The HSPRN receives funding from the Ontario Ministry of Health and Long- Term Care (MOHLTC). The views expressed here are those of the authors with no endorsement from the MOHLTC. We thank the MOHLTC Transformation Secretariat and the HSPRN Research Team for their support and suggestions. Particular thanks go to Goncalo Santos for assistance preparing this report, and Peter Gozdyra for all geographic information system assistance. Competing Interests: The authors declare that they have no competing interests. Reproduction of this document for non-commercial purposes is permitted provided appropriate credit is given. Cite as: Kromm S, Mondor L, Wodchis WP. Assessing Value in Ontario Health Links. Part 3: Measures of System Performance in Ontario’s Health Links. Applied Health Research Question Series. Volume 4. Toronto: Health System Performance Research Network; 2015. This report is available at the Health System Performance Research Network Website: http://hsprn.ca. For inQuiries, comments, and corrections please email [email protected]. 2 Executive Summary Context Ontario’s Health Links (HL) initiative was launched in January 2013 to improve the coordination of care provided to patients with the most complex healthcare needs. This group of patients represents a small minority of the Ontario population (5%), but accounts for a majority of health system costs (66%). Health Links are a novel method of delivering integrated health care services to Ontarians. They are geographically defined, and each Health Link is given the flexibility to identify its target population and improve integration of care for complex, high-needs patients. Given the considerable efforts that are being invested in HLs, reporting on the system performance of HLs is an important priority. Objective This report responds to an Applied Health Research Question (AHRQ) from the Ontario Ministry of Health and Long-Term Care (MOHLTC) Transformation Secretariat, with specific interest in the identification of value that Health Links add to the health system, such as avoided hospitalizations, reduced complications of care, improved quality of life, etc. In this report we: 1) describe the characteristics of the population in Health Links regions; 2) measure health system performance in HL regions using data held at the Institute for Clinical Evaluative Sciences (ICES), creating a portrait of HLs that can be used in the future; and 3) compare system performance among HLs and to existing physician networks (PN), defined by referral patterns among primary care physicians. Methods Based on results from reports 1 and 2 in this series, twenty-two indicators were identified, defined, and categorized according to the Institute for Healthcare Improvement’s (IHI) Triple Aim framework: better care and experience for individuals, better health for populations, and lower growth in healthcare costs. Six of these indicators are the focus of this report: 1. average monthly costs, 2. the rate of hospitalization, 3. the rate of emergency-department visits for non-critical patients, 4. rate of 30-day readmissions, 5. primary care follow-up within 7 days of hospital discharge, 6. and the proportion of individuals rostered to a primary care physician. Ontario residents with a valid health card on April 1, 2012 were assigned to an HL according to the location of their usual provider of primary care (90.2%) or home residence (9.8%), based on geographical boundaries defined by the MOHLTC. Using cohorts of 1) all Ontarians and 2) the top 5% high-cost users, indicator values for HLs were determined with data from the 2012 fiscal year. 3 Individual Health Link performance was compared to the provincial average across HLs for each of the indicators. HLs were categorized according to whether they adopted the initiative early or not (‘early adopters’), their degree of rurality according to the Rurality Index of Ontario (RIO), and measurable health ineQuities between geographical regions or populations according to the Ontario Marginalization Index (ON-Marg). A total Zscore using data from all indicators was created for HLs for both cohorts of interest to assess whether HLs were performing differently in the two populations. Findings Demographic measures among HLs were comparable to provincial data for both the full population of residents and the top 5% of users. For the six selected indicators, a general comparison of HL performance to the provincial average did not reveal differences between early and later adopter HLs, but did reveal pockets of high and low performance. With respect to rurality, urban HLs had lower cost and lower ED-visit rates compared to the provincial average. Alternatively, suburban and rural HLs had higher rates of primary care rostering compared to the provincial average. Socio-economic status was found to be highly related to system performance indicators, with high levels of marginalization corresponding to lower performance, and a strong relationship between performance in the full population and among the top 5% of health care users. Although rural and low SES groups have lower performance than urban and high SES, there is substantial variation within these groupings, offering opportunities for comparative performance and potential learning from peer groups of HLs with similar local challenges. Comparisons showed substantial variation and overlap across all performance indicators for both Health Link and Physician Networks. We also found that there was only a moderate degree of overlap in patient populations between specific pairs of Health Links and Physician Networks. We examined the proportion of residents common to both the Health Link and the Physician Network that had the highest degree of overlap with each Health Link. We found that an average of only 46% of patients in Health Links overlapped with the Physician Network that shared the most patients in common. Conclusions The performance of HLs on the indicators used for this report can inform benchmarking and be used for further analyses over time. Differences in performance based on rurality and marginalization highlight important contextual factors for HL leaders and decision makers to consider when comparing performance across HLs, particularly how to group HLs with appropriate peer-comparators. Identifying the specific effect of HLs on patient care and outcomes reQuires the ability to identify which individuals are enrolled in HL programs. A registry of Health Links patients is essential to any measurement of value of HLs or evaluation of performance of HLs on the heath of individuals and populations. This was not possible at the time of this report. Instead, the present report describes the general population trends of patients in HL geographies, but does not evaluate the performance of HLs specifically in regard to the patients who are enrolled in HL programs. 4 The Triple Aim Framework highlights a gap in the current focus of HL assessment: there are no indicators being used to track the performance of HLs on population health measures. Population health can have significant effects on health system performance measures, especially considering the results of the analyses based on rurality and marginalization. Achieving effective inter-organizational integration across the care continuum is a challenging and important goal for Ontario’s health care system. Effective and timely approaches to identifying which patients to target for HL interventions and knowing which providers to engage will be key factors in the success of HLs. Differences in existing patterns of care for patients among PNs, compared to the geographic approach employed by HLs continue to present challenges for HLs to effectively manage care for complex patients. The model of Accountable Care Organizations described in the first report of this series could be pursued in Ontario based either on geographic boundaries, or enrolment models following existing practice patterns; it will be highly challenging to enable accountability and provide equitable funding with a hybrid approach. Full population-based accountability will require either that patients be willing to change primary care providers or that Health Links be reorganized to engage with providers in their referral network regardless of geography. 5 Table of Contents Executive Summary ...................................................................................................................................... 3 List of Tables ................................................................................................................................................. 7 List of Figures ............................................................................................................................................... 7 Context ......................................................................................................................................................... 8 Objectives ....................................................................................................................................................
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